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STATE OF CALIFORNIks'' WATER RESOURCESCONTROLVOARD t. FORM 'A': UNDERGROUND STORAGE TANK PROGRAM LA,0 Z SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m io l� COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT Jf 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ock ,, IJru,� fe•>a+�ce S +roN ADDRESS NEAREST CROSS STREET ✓Sox 10 Ali ❑ PARTNERSHIP ❑ STATE AGENCY C CORPORATION ❑ LOCALAGENCY C FEDERAL-AGBILY ❑ INDIVIDUAL ❑ COUNTY- AGENCY CITY NAME STATE ZIP CODE SITE PHONE it WITH AREA CODE CA 5206 TYPE OF BUSINESS: ❑ @ DISTRIBUTOR 4 PROCESSOR ✓Box B INDIAN EPA ID a N of TANK's RESERVATION or ❑ AT THIS SITE ❑ 1 GAS STATION ❑ J FARM ❑ 5OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax to indicate C PARTNERSHIP C STATE AGENCY C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY C INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP C STATE-AGENCY ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY W FACILITY ID R R of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE It WITH AREA CODE 1 PERMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPE SOR-OISTRICT'i CODE BUSINESS PLAN FILED I DATE FI D OYES NO U CHECK It PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: cff THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANKPE FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON FORM A(3-2-88) l DATA PROCESSING COPY